Background
Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated.
Methods
A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem.
Results
Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “
Training and retention of specialist staff
”, “
Health education/awareness of injury severity
”, “
Geographical coverage of referral trauma centres
”, and “
Lack of protocol for bypass to referral centres
”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map.
Conclusion
Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.
Introduction Acute kidney injury (AKI) requiring renal replacement therapy is associated with high mortality. The study assessed the impact of the introduction of hemodialysis (HD) on outcomes of patients with AKI in Rwanda. Methods A single center retrospective study that evaluated the clinical profile and survival outcomes of patients with AKI requiring HD [AKI-D] at a tertiary hospital in Rwanda. Data was collected on patients who received HD for AKI from September 2014 to December 2016. Patient demographics, comorbidities, clinical presentation, laboratory tests, and mortality were reviewed and analyzed. Predictors of mortality were assessed using age and gender adjusted multivariate analyses. Results Of the 82 eligible patients, median age was 38 years (IQR 28–57 years). Males comprised 51% of the cohort. Infectious diseases including malaria, pneumonia, and sepsis (35.1%) and pregnancy-related conditions (26.9%) were the most frequent comorbidities. Pulmonary oedema (54.9%) and uremic encephalopathy (50%) were top indications for HD. Mortality was 34.1%. On multivariate analysis, receipt of <5 sessions of HD (OR = 4.01, 95% CI 1.185–13.61, P = 0.026) and hyperkalemia (OR = 3.23, 95% CI 1.040–10.065, P = 0.043) were associated with mortality. Conclusion The availability of acute hemodialysis in Rwanda has resulted in improved patient survival and persistent hyperkalemia predicted higher mortality.
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